The Medicare Claims Processing Manual has been updated to address prolonged services codes in order to be consistent with changes/deletions in codes and changes in typical/average time units in the American Medical Association Current Procedural Terminology (CPT) coding system. The manual changes define Prolonged Services and explain the required evaluation and management (E&M) companion codes.
Prolonged Services Definitions
– In the office or other outpatient setting
o Medicare will pay for prolonged physician services (CPT code 99354) with direct face to face patient contact that requires one hour beyond the usual service when billed on the same day by the same physician or qualified NPP as the companion E&M codes. The time for usual service refers to the typical/average time units associated with the companion E&M service as noted in the CPT code. Each additional 30 minutes of direct face to face patient contact following the first hour of prolonged services with CPT code 99355.
– In the inpatient setting
o Medicare will pay for prolonged physician services (code 99356) with direct face to face patient contact which requires one hour beyond the usual service when billed on the same day by the same physician or qualified NPP as the companion E&M codes. Each additional 30 minutes of direct face‐to‐face patient contact following the first hour of prolonged services with CPT code 99357.
You should not separately report prolonged service of less than 30 minutes total duration on a given date, because the work involved is included in the total work of the E&M codes.
You may use code 99355 or 99357 to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15-30 minutes of prolonged service on a given date, if not otherwise billed. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.
Note: Prolonged Service Codes 99354 – 99357 are NOT paid unless they are accompanied by the appropriate visit specific E&M companion codes.
Requirement for Physician Presence
You may count only the duration of direct face‐to‐face contact with the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed, to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable.
You cannot bill as prolonged services:
– In the office setting, time spent by office staff with the patient or time the patient remains unaccompanied in the office.
– In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct face‐to‐face contact with the patient or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities.
Documentation
Unless you have been selected for medical review, you do not need to send the medical record documentation with the bill for prolonged services. Documentation, however, is required to be in the medical record about the duration and content of the medically necessary E&M services and prolonged services that you bill.
You must appropriately and sufficiently document in the medical record that you personally furnished the direct face‐to‐face time with the patient specified in the CPT code definitions. Make sure that you document the start and end times of the visit, along with the date of service.
Use of the Codes
You can only bill the prolonged services codes if the total duration of a physician or qualified NPP direct face‐to‐face service (including the visit) equals or exceeds the threshold time for the E&M service the physician or qualified NPP provided (typical/average time associated with the CPT E&M code plus 30 minutes).
Threshold Times for Codes 99354 and 99355 (Office or Other Outpatient Setting)
If the total direct fact‐to‐face time equals or exceeds the threshold time for code 99354, but is less than the threshold time for code 99355, you should bill the E&M visit code and code 99354. No more than one unit of 99354 is acceptable.
If the total direct face to f ace time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, you should bill the visit code 99354 and one unit of code 99355. One additional unit of code 99355 is billed for each additional increment of 30 minutes extended duration.
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